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States Can Limit Emergency Access in Medicaid Cases Fri Jan 17, 9:01 AM ET Add to My Yahoo! By ROBERT PEAR The New York Times WASHINGTON, Jan. 16 In a reversal, the Bush administration has ruled that managed care organizations can limit and restrict coverage of emergency services for poor people on Medicaid. The new policy, disclosed in a recent letter to state Medicaid directors, appears to roll back standards established in a 1997 law and in rules issued by the Clinton administration in January 2001 and by the Bush administration itself in June 2002. Under the 1997 law, states can require Medicaid recipients to enroll in health maintenance organizations or other types of managed care. But certain safeguards for patients were built into that law. Congress, for example, stipulated that managed care organizations had to provide coverage for Medicaid patients in any situation that a "prudent layperson" would regard as an emergency. Now the Bush administration has decided that states can place certain limits on coverage of emergency services "to facilitate more appropriate use of preventive care and primary care," the letter said. Administration officials said today that the new policy was consistent with President Bush ( - )'s desire to give states greater flexibility in the operation of their Medicaid programs. "Some states felt restricted and constricted by the old policy," said Gregory A. Vadner, the Missouri Medicaid director, who is also vice chairman of the National Association of State Medicaid Directors. "In a time of fiscal stress for states, it's all the more important that we have discretion to manage programs properly." States say they are facing the worst fiscal crisis in more than 50 years and are desperately looking for ways to control health costs. Many have cut benefits or restricted eligibility in an effort to hold down Medicaid costs, which rose 13 percent in the last fiscal year, the biggest increase in a decade. But Cindy Mann, a Medicaid expert at Georgetown University, questioned the legality of the new policy. Senator Bob Graham, Democrat of Florida, a principal author of the 1997 law, said the new policy "would undermine access to essential emergency services for low-income Americans," including children, the elderly and the disabled. Mr. Graham said he did not understand how the administration could, by a letter, make such profound changes in a policy established by statute. Administration officials said the basic Medicaid law allowed states to set reasonable limits on the amount, duration and scope of services. The letter was sent to state officials by Dennis G. Smith, the Bush administration official in charge of Medicaid. Under the old policy, Mr. Smith said, states could not limit coverage of emergency services for Medicaid beneficiaries in managed care. "When the prudent layperson standard is met," the old policy said, "no restriction may be placed on access to emergency care. Limits on the number of visits are not allowed." More than 40 million people are insured through Medicaid. More than 55 percent of them are in some type of managed care. The letter does not specifically say what kind of limits can be imposed, but state officials have discussed ideas like limits on the number of emergency room visits that would be covered. Ben A. Bearden, the Medicaid director in Louisiana, said his state wanted to limit Medicaid coverage for adults to three emergency room visits a year. "Three emergency visits a year for an adult may sound like a small number, but it's really not," Mr. Bearden said today in an interview. "I'm 60 years old, and I've been to an emergency room once in my life. The E.R. is very expensive, and people in this state use it inappropriately. They go in for a stubbed toe." Louisiana used to have a three-visit limit, Mr. Bearden said, but, at the insistence of federal Medicaid officials, the state ended the restriction for people in managed care a couple of years ago. Under one form of managed care, states pay primary care doctors to coordinate care for Medicaid recipients. Mark D. Trail, the Medicaid director in Georgia, said that prior to 1997, his state required an emergency room to get authorization from the primary care doctor before treating a Medicaid patient enrolled in the state's managed care plan. Georgia did away with that requirement because of the 1997 law. "Since then," Mr. Trail said, "use of hospital emergency rooms has spiked," and the state is seeking ways to reduce inappropriate use. Mr. Vadner, the Missouri official, said states recognized their obligation to cover emergency care. But there is often a dispute over who should pay and what services are needed. Michelle Mickey, a policy analyst at the National Association of State Medicaid Directors, said state officials had sought a clarification of federal policy on emergency care. The new policy, she said, is "above and beyond what the states ever requested or expected." Senator Graham introduced a bill to establish the "prudent layperson" standard for all insurers in 1997. The standard was included in the Balanced Budget Act of 1997, as a requirement for managed care plans serving people in Medicaid or Medicare. The purpose, Mr. Graham said, is "to allow a person who reasonably believes that he or she is undergoing an emergency condition to be evaluated, treated and stabilized in the emergency room without fear that the health plan will later deny the claim." A prudent layperson is defined in the law as a person with "an average knowledge of health and medicine." Doctors and hospitals said the prudent layperson standard was needed because H.M.O.'s had often refused to pay for emergency care after concluding that there was no real emergency if, for example, chest pains resulted from severe indigestion rather than a heart attack. Under the law, the managed care plan is supposed to pay for the emergency care, regardless of whether the patient got "prior authorization." The patient can go to the nearest hospital, regardless of whether it is in the health plan's network of providers. The Bush administration issued rules interpreting the law on June 14, 2002. In a news release at the time, the administration said, "Health plans must pay for a Medicaid beneficiary's emergency room care whenever and wherever the need arises." _______________________________________________ http://www.mccmedia.com/mailman/listinfo/brin-l
